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Provide the following information for every firm (DBE and non-DBE) - �• -.project, Firm Name: -I . obtain a contract.- Phone: Firm Address: FAX: ( ) - - Type of work/services /materials provided: Number of years in business: Contact Person: Title: Is the firm currently certified as a DBE under 49 CFR Part 26? Yes .No . Check the box below for your firm's annual gross receipts last year: DBE Certification Eligibility (place an "X "): African American _Asian Pacific American _Native American _Woman _Hispanic American _Subcontinent Asian American Other Less than $1 million Less than $5 million Less than $10 million Less than $15 million More than $15 million Firm Name: Phone: " () - Firm Address: FAX: ( ) - - Number of years in business: Type of work/services /materials provided: Contact Person: Title: Is the firm currently certified as a DBE under 49 CFR Part 26? Yes .No . Check the box below for your firm's annual gross receipts last year: DBE Certification Eligibility (place an "X "): African American _Asian Pacific American _Native American _Woman _Hispanic American _Subcontinent Asian American Other Less than $1 million Less than $5 million Less than $10 million Less than $15 million More than $15 million Page 47 of 48 19H -51